SHARE YOUR STORY

We love learning how principled chiropractic care is changing your body, your health, and your life. It is why we do what we do, and our team and practice members are encouraged whenever they hear these stories. You can help ignite a passion for true health and healing in our community by sharing your own personal health story!

All you need to do is write in your own words, in the spaces provided below, your chiropractic story. Use the instructions and questions provided as a guide. Once you have submitted this form, we will take and attach a photo of you (if you are okay with that). Thank you for sharing your story! We really appreciate it!!


Some questions to help guide your story:

Name *
Name
Photography | Video | Privacy Notice
For valuable consideration, I hereby irrevocably consent to and authorize the use and reproduction by Restore Chiropractic, or anyone authorized by Restore Chiropractic, of any and all photographs/videos which you have this day taken of me, for the purpose of promotional TV and/or print ad whatsoever, without further compensation to me. All negatives and positives, together with the prints shall constitute the property of Restore Chiropractic, solely and completely. Any information voluntarily provided by a patient shall also be used in conjunction with the above listed information for purposes previously mentioned. Confidentially, in regards to any reported conditions, is also waived to the extent of the information pertinent to the promotion material only. All other unrelated patient information shall remain private and protected (according to the Health Information and Privacy Act laws).
Print Name:
Print Name:
Your printed name below represents your signature of consent for Restore Chiropractic to take and utilize photos and videos as stated above.
Date:
Date: